Mods, this may not be fully in the spirit of our summa princeps GTS's idea for this board, but request grace because the discussion here is more sane and civil.

Now if I had my druthers, a Singapore system where people are forced to save to pay all but catastrophic expenses would be the path. I just don't see that being politically viable.

I think a Bismarck system is more viable to be accepted. The problem is getting from the point we are at to the point of such a system requires passing through some other point(s).

The flavors of the Nixon, Romney, Obama plans while following similar concepts had different implementation ideas. The general concept was conceived by conservative think tanks. On reflection I think they all suffer the same problem. The assumption that if all are covered by an insurance scheme that prices will come into some sort of sane order.

I think that is a flawed assumption because it rewards providers to bill as much as they can to maximize income. It encourages even more "if you have diabetes", "if you are incontinent", "if you need a scooter", "if you have restless legs" type advertising to drum up more billings.

So how to get from the point we are at to the point of a Bismarck plan?

I think step one is to try to do two things that will be hard to achieve but are closer to being achieved than a full blown Bismarck plan.

Part 1. We have a law that provides that any hospital accepting Medicare cannot turn away an emergent patient lacking insurance or means to pay, they are required to provide enough treatment to get the patient stable.

In that same vein, the first leg of my idea is that any PROVIDER who accepts Medicare, Medicaid, VA third party patients, Tricare or Federal employee insurance cannot charge an uninsured patient more than some percentage of what Medicare would allow. Let's say 120% for a starting point.

This actually doesn't just impact the person the we think of as uninsured. If you are in a car wreck where you are not at fault your insurance can deny coverage and you pay sticker price for treatment out of any settlement unless you can negotiate them down.

Part 2. When Medicare Part D was adopted to get it passed George W Bush agreed to a provision prohibiting Medicare from negotiating drug prices, so stuck paying sticker prices the program has been a financial pit and contributed to rising prices. Just change it so Medicare looks at the prices negotiated by the companies providing insurance for Federal employees. Take the three highest negotiated prices and Medicare pays the average of those.

THE REASONING.
Prices fixed by the state is an essential element of a Bismarck plan, limiting just prices for the uninsured and taking higher end prices for drugs is at least plausible to get adopted. Still a hard fight but at least possibly within reach.

I'd just like to see posted prices. It should be law, just as with autos. Sure they will be MSRP. but it's a start.

They actually have those in Europe and Asia.

You cannot have market economics without prices, and without choices. If you knew you could get a MRI at place "A" done for $200 and at place "B" for $3000, it's pretty obvious what you'd do. But most health care providers are "vertically integrated" meaning you will be sent to the in-house lab. It might be fair priced, it might not.

Also I can tell you stories about how one DNA test was done on my brother's wife and they tried to go after the insurance company for $6000 and pressured my brother (the insurance company said no). When the provider determined they couldn't do that, they sent my brother a bill for under $300. Hum, he thought that was fair, as that is close to the actual price most tests run. This is the sort of thing that happens without prices being in the daylight, and part of the whole scam of insurance fees.

Government taking over the costs does not remedy any of the problem of secrecy. And minor changes to this or that, might save a few bucks here or there, but they fundamentally do not change the system or open up competition (in fact they may help drive innovators out by removing market access with typical "fill 10,000 orders or else no deal" type contracts).

Medicine, like Education is a product, or rather a package of services and products. But for too long prices are hidden and market forces not able to impact much. Instead we have cartels that build in inflation. For them it's a win-win to have more government regulation. But it's the wrong path to go, and we have been on that path for generations. We now spend almost 1 in 6 dollars on health care, for essentially the same outcome results that countries in Asia spent about 1 in 20 dollar on.

Again the one reform I care about, and can happen without anything else happening and without any political pain for anyone, is to require all costs and bills be published and available to patients, even if it's paid 100% by their insurance. We need to see the truth in the daylight.

(04-25-2018 11:56 PM)arkstfan Wrote:  Mods, this may not be fully in the spirit of our summa princeps GTS's idea for this board, but request grace because the discussion here is more sane and civil.
Now if I had my druthers, a Singapore system where people are forced to save to pay all but catastrophic expenses would be the path. I just don't see that being politically viable.
I think a Bismarck system is more viable to be accepted. The problem is getting from the point we are at to the point of such a system requires passing through some other point(s).
The flavors of the Nixon, Romney, Obama plans while following similar concepts had different implementation ideas. The general concept was conceived by conservative think tanks. On reflection I think they all suffer the same problem. The assumption that if all are covered by an insurance scheme that prices will come into some sort of sane order.
I think that is a flawed assumption because it rewards providers to bill as much as they can to maximize income. It encourages even more "if you have diabetes", "if you are incontinent", "if you need a scooter", "if you have restless legs" type advertising to drum up more billings.
So how to get from the point we are at to the point of a Bismarck plan?
I think step one is to try to do two things that will be hard to achieve but are closer to being achieved than a full blown Bismarck plan.
Part 1. We have a law that provides that any hospital accepting Medicare cannot turn away an emergent patient lacking insurance or means to pay, they are required to provide enough treatment to get the patient stable.
In that same vein, the first leg of my idea is that any PROVIDER who accepts Medicare, Medicaid, VA third party patients, Tricare or Federal employee insurance cannot charge an uninsured patient more than some percentage of what Medicare would allow. Let's say 120% for a starting point.
This actually doesn't just impact the person the we think of as uninsured. If you are in a car wreck where you are not at fault your insurance can deny coverage and you pay sticker price for treatment out of any settlement unless you can negotiate them down.
Part 2. When Medicare Part D was adopted to get it passed George W Bush agreed to a provision prohibiting Medicare from negotiating drug prices, so stuck paying sticker prices the program has been a financial pit and contributed to rising prices. Just change it so Medicare looks at the prices negotiated by the companies providing insurance for Federal employees. Take the three highest negotiated prices and Medicare pays the average of those.
THE REASONING.
Prices fixed by the state is an essential element of a Bismarck plan, limiting just prices for the uninsured and taking higher end prices for drugs is at least plausible to get adopted. Still a hard fight but at least possibly within reach.

I agree that Bismarck is the way to do. I do have a couple of quibbles with your post.

One, Bismarck fixes prices for only a part of the system, the part covered by the basic plans (the "free" side). The rest of the system (the "pay" side) operates on a free market basis. Whenever you fix prices, you will have shortages, guaranteed. It is the very viable free market pay side that covers the shortages in the free side that makes it work, that makes something like the Alfie fiasco in UK not happen under Bismarck.

Two, I think you are equating the Nixon, Romney, and Obamacare plans far too closely, and stating that they all came from conservative think tanks is not true. Nixon predated the Heritage plan by two decades, so he clearly didn't get his ideas from it. And the three are different in substantial ways, and all are substantially different from Heritage. For a couple of examples. One, Heritage included interstate purchases of health insurance, but there's a problem with that. You don't have people in Georgia selling Oregon health insurance policies, at least not initially. So you borrow the idea of exchanges from Bismarck Germany, where they are used for precisely that purpose, to facilitate interstate purchases of insurance. In Germany, each of the states (lander) has its own insurance fund which offers a variety of policies, and you can buy from any state, not just the one were you live. But Romneycare, as a state system, didn't address this issue, and Obamacare did not allow interstate purchases, so the Obamacare exchanges were just a borrowed name without the accompanying idea. Kind of a way to be deceptive, which is a theme throughout Obamacare. Two, Obamacare supposedly got the mandate from Heritage, but there's a big difference. Heritage proposed a mandate to buy health insurance, but with a tax credit up to the cost of a basic policy for those who did obtain insurance. Obamacare had the mandate without the financial incentive, so it never got anything close to 100% participation. Also, Heritage gave everybody the tax credit, it wasn't. means-tested like the Obamacare subsidies. Basically, Heritage was a variant of Bismarck without calling itself that.

What I'd like to see is Bismarck with the Singapore approach as an option. Everybody gets a basic policy free. Different carriers compete to provide the basic policy. One option they would have to offer is a catastrophic option, wit the insured also establishing a Health Spending Account to cover up to the catastrophic coverage floor, and the HSA would have all the carryover and transportability features that republicans have proposed. I think what you'd see happening pretty quickly is the insurers underwriting alternative care options (doc in a box, more stuff being done nurse practitioners/physician's assistants instead of full fledged docs) to bend the cost curve down.

I don't really see either of your Steps 1 or 2 being necessary or appropriate to shift to Bismarck. You could actually get there pretty quickly from Obamacare by changing the mandate to a formula that will generate 100% participation, and by getting rid of most of the paperwork bureaucracy that Obamacare and prior laws have imposed.

(04-30-2018 04:26 PM)Owl 69/70/75 Wrote:  

(04-25-2018 11:56 PM)arkstfan Wrote:  Mods, this may not be fully in the spirit of our summa princeps GTS's idea for this board, but request grace because the discussion here is more sane and civil.
Now if I had my druthers, a Singapore system where people are forced to save to pay all but catastrophic expenses would be the path. I just don't see that being politically viable.
I think a Bismarck system is more viable to be accepted. The problem is getting from the point we are at to the point of such a system requires passing through some other point(s).
The flavors of the Nixon, Romney, Obama plans while following similar concepts had different implementation ideas. The general concept was conceived by conservative think tanks. On reflection I think they all suffer the same problem. The assumption that if all are covered by an insurance scheme that prices will come into some sort of sane order.
I think that is a flawed assumption because it rewards providers to bill as much as they can to maximize income. It encourages even more "if you have diabetes", "if you are incontinent", "if you need a scooter", "if you have restless legs" type advertising to drum up more billings.
So how to get from the point we are at to the point of a Bismarck plan?
I think step one is to try to do two things that will be hard to achieve but are closer to being achieved than a full blown Bismarck plan.
Part 1. We have a law that provides that any hospital accepting Medicare cannot turn away an emergent patient lacking insurance or means to pay, they are required to provide enough treatment to get the patient stable.
In that same vein, the first leg of my idea is that any PROVIDER who accepts Medicare, Medicaid, VA third party patients, Tricare or Federal employee insurance cannot charge an uninsured patient more than some percentage of what Medicare would allow. Let's say 120% for a starting point.
This actually doesn't just impact the person the we think of as uninsured. If you are in a car wreck where you are not at fault your insurance can deny coverage and you pay sticker price for treatment out of any settlement unless you can negotiate them down.
Part 2. When Medicare Part D was adopted to get it passed George W Bush agreed to a provision prohibiting Medicare from negotiating drug prices, so stuck paying sticker prices the program has been a financial pit and contributed to rising prices. Just change it so Medicare looks at the prices negotiated by the companies providing insurance for Federal employees. Take the three highest negotiated prices and Medicare pays the average of those.
THE REASONING.
Prices fixed by the state is an essential element of a Bismarck plan, limiting just prices for the uninsured and taking higher end prices for drugs is at least plausible to get adopted. Still a hard fight but at least possibly within reach.

I agree that Bismarck is the way to do. I do have a couple of quibbles with your post.

One, Bismarck fixes prices for only a part of the system, the part covered by the basic plans (the "free" side). The rest of the system (the "pay" side) operates on a free market basis. Whenever you fix prices, you will have shortages, guaranteed. It is the very viable free market pay side that covers the shortages in the free side that makes it work, that makes something like the Alfie fiasco in UK not happen under Bismarck.

Two, I think you are equating the Nixon, Romney, and Obamacare plans far too closely, and stating that they all came from conservative think tanks is not true. Nixon predated the Heritage plan by two decades, so he clearly didn't get his ideas from it. And the three are different in substantial ways, and all are substantially different from Heritage. For a couple of examples. One, Heritage included interstate purchases of health insurance, but there's a problem with that. You don't have people in Georgia selling Oregon health insurance policies, at least not initially. So you borrow the idea of exchanges from Bismarck Germany, where they are used for precisely that purpose, to facilitate interstate purchases of insurance. In Germany, each of the states (lander) has its own insurance fund which offers a variety of policies, and you can buy from any state, not just the one were you live. But Romneycare, as a state system, didn't address this issue, and Obamacare did not allow interstate purchases, so the Obamacare exchanges were just a borrowed name without the accompanying idea. Kind of a way to be deceptive, which is a theme throughout Obamacare. Two, Obamacare supposedly got the mandate from Heritage, but there's a big difference. Heritage proposed a mandate to buy health insurance, but with a tax credit up to the cost of a basic policy for those who did obtain insurance. Obamacare had the mandate without the financial incentive, so it never got anything close to 100% participation. Also, Heritage gave everybody the tax credit, it wasn't. means-tested like the Obamacare subsidies. Basically, Heritage was a variant of Bismarck without calling itself that.

What I'd like to see is Bismarck with the Singapore approach as an option. Everybody gets a basic policy free. Different carriers compete to provide the basic policy. One option they would have to offer is a catastrophic option, wit the insured also establishing a Health Spending Account to cover up to the catastrophic coverage floor, and the HSA would have all the carryover and transportability features that republicans have proposed. I think what you'd see happening pretty quickly is the insurers underwriting alternative care options (doc in a box, more stuff being done nurse practitioners/physician's assistants instead of full fledged docs) to bend the cost curve down.

I don't really see either of your Steps 1 or 2 being necessary or appropriate to shift to Bismarck. You could actually get there pretty quickly from Obamacare by changing the mandate to a formula that will generate 100% participation, and by getting rid of most of the paperwork bureaucracy that Obamacare and prior laws have imposed.

The problem with interstate insurance is what makes the price low (negotiating lower service prices) does you no good in most cases. If North Carolina Mutual convinces doctors and hospitals to take lower prices because they can deliver high volume and guarantee faster turn around of claims, that won't do you much good in Texas if none of the providers are accepting that price, that leaves the consumer paying out-of-network prices. Texas Star Memorial Hospital can charge sticker price to the North Carolina consumer and be reimbursed only the out-of-network price.

You can go bankrupt just as fast.

Now the flip side is the intra-state system creates its own set of problems. If I am in a catastrophic car wreck driving home they will send me via helicopter to a hospital that my insurer almost certainly has a contract with. If I am working in Northeast Arkansas, the helicopter is taking me to Memphis and who knows if there is a deal.

No system that deals solely with coverage is going to be cost-efficient. We could have 100% coverage but medical inflation is not going to slow much and you cannot have a Bismarck system where all claims are paid without some other control and not have high inflation.

Increasing the supply of money will create inflation.

You have to shift the claim denial system from provider/patient relationship to the provider/payer relationship. With the payer able to pursue to contract breach or make referral for fraud.

I have a rather out-of-character suggestion and I have thought as much for a long time now: government medical and nursing schools with free or greatly reduced tuition.

We always talk about a lack of tradesmen and how being a tradesman is a great job. Why don't we have the same type of early learning, just out of high school opportunities for nursing assistants, dental hygienists, and other more entry level medical jobs? Perhaps government medical and nursing schools with free or greatly reduced tuition are a great option. Two years intense study, then a job. Just like tradesmen.

(Hell, even full on MDs! If it really that hard to be a GP? Or a dentist? My buddy is a gastroenterologist. After a few beers he will readily admit he knows everything from your throat through your butthole, but doesn't remember just about anything else from medical school. He was laughing just yesterday that someone at work commented about a the name of a bone and he thought is was in the foot when it was actually in the hand.)

Leaving out the arguments about capitalism, responsibility, quality of care etc, I think a conversation should be had about the lack of medical professionals (and in poor inner cities or rural and remote areas, specifically, and how that drive healthcare costs)

This can be done. Churn them out, at least at the lower / entry levels. Save me the comments about why this can't be done, I'd love a convo on what we need to get it done.

(05-02-2018 08:29 AM)Lord Stanley Wrote:  I have a rather out-of-character suggestion and I have thought as much for a long time now: government medical and nursing schools with free or greatly reduced tuition.
We always talk about a lack of tradesmen and how being a tradesman is a great job. Why don't we have the same type of early learning, just out of high school opportunities for nursing assistants, dental hygienists, and other more entry level medical jobs? Perhaps government medical and nursing schools with free or greatly reduced tuition are a great option. Two years intense study, then a job. Just like tradesmen.
(Hell, even full on MDs! If it really that hard to be a GP? Or a dentist? My buddy is a gastroenterologist. After a few beers he will readily admit he knows everything from your throat through your butthole, but doesn't remember just about anything else from medical school. He was laughing just yesterday that someone at work commented about a the name of a bone and he thought is was in the foot when it was actually in the hand.)
Leaving out the arguments about capitalism, responsibility, quality of care etc, I think a conversation should be had about the lack of medical professionals (and in poor inner cities or rural and remote areas, specifically, and how that drive healthcare costs).
This can be done. Churn them out, at least at the lower / entry levels. Save me the comments about why this can't be done, I'd love a convo on what we need to get it done.

This is one way the French cut medical costs. If you agree to work for a salary on the "free" side for a specified number of years before going into private practice, you get med school paid for. And they have time to develop and gain experience in a specialty before crossing over the the "pay" side.

The armed services have done that for years here. You could fairly rapidly populate a low cost pool of GPs, PAs, and NPs to provide basic care.

I think if we went to a Bismarck approach, one side effect would be to incentivize the health insurance industry, which has the financial resources, to develop lower cost alternative channels for providing health care.

(05-02-2018 08:29 AM)Lord Stanley Wrote:  I have a rather out-of-character suggestion and I have thought as much for a long time now: government medical and nursing schools with free or greatly reduced tuition.

We always talk about a lack of tradesmen and how being a tradesman is a great job. Why don't we have the same type of early learning, just out of high school opportunities for nursing assistants, dental hygienists, and other more entry level medical jobs? Perhaps government medical and nursing schools with free or greatly reduced tuition are a great option. Two years intense study, then a job. Just like tradesmen.

(Hell, even full on MDs! If it really that hard to be a GP? Or a dentist? My buddy is a gastroenterologist. After a few beers he will readily admit he knows everything from your throat through your butthole, but doesn't remember just about anything else from medical school. He was laughing just yesterday that someone at work commented about a the name of a bone and he thought is was in the foot when it was actually in the hand.)

Leaving out the arguments about capitalism, responsibility, quality of care etc, I think a conversation should be had about the lack of medical professionals (and in poor inner cities or rural and remote areas, specifically, and how that drive healthcare costs)

This can be done. Churn them out, at least at the lower / entry levels. Save me the comments about why this can't be done, I'd love a convo on what we need to get it done.

The studies that compare compensation for health professionals across countries normally find that US medical professionals do much better financially but when taking into account their need to service education loans the gap nearly disappears.

Right now we have a logjam. We are expanding medical education, primarily with DO schools but not increasing the number of residencies at the same pace. The new residencies tend to be in the same region as the new med schools and are being funded by the local hospitals who are struggling to fill their positions.

We are taking a bit of a trade school approach already with PA's or APN's. My cousin and her husband are both doctors and their niece was interested in becoming a GP, they both encouraged her to do the APN route because she could be out working faster with not a big difference in income. Specialists are starting to hire APNs as well.

Just allow everyone to buy into Medicare. Double the number of medical school slots and make those slots only for doctors that promise to serve Medicare patients for the remainder of their American medical careers. Block Insurance companies from taking profits from reserves as a result of reductions in coverage, or number of covered persons. Tie US pharmaceutical prices to the G20 average price. Bar NIH or other Federal grant research money to facilities that discriminate against Medicare patients. Make Medicare means based. Require all Certificate of Need, taxpayer supported, or research grant holding facility to participate in Medicare. Bar doctors discriminating against Medicare patients from having admitting rights at any Certificate of Need, Research grant receiving, or Public hospital. Monetize our taxpayer supported internship hospitals (pretty much all of them) and charge doctors for the cost of their internship. If the doctor chooses to not serve Medicare/VA patients, then they shall be responsible for paying back the taxpayers for the cost of that education.


Since corporations would get a massive benefit due to the fact that healthcare would now be a means based entitlement, and they'd be no longer required to provide coverage, it makes sense to finance it partially from a 10 percent corporate surtax. I think most companies would gladly make that switch.

Private doctors and insurance companies would still exist. They'd just not be living off of government subsidies while doing so. I doubt that many would be able to make much of a living doing so though.

And yes, people would still be doctors, just like they are in every other country in the G20, all of whom have medical systems that have means based healthcare of one form of another.

(05-07-2018 03:23 PM)Tom in Lazybrook Wrote:  Just allow everyone to buy into Medicare. Double the number of medical school slots and make those slots only for doctors that promise to serve Medicare patients for the remainder of their American medical careers. Block Insurance companies from taking profits from reserves as a result of reductions in coverage, or number of covered persons. Tie US pharmaceutical prices to the G20 average price. Bar NIH or other Federal grant research money to facilities that discriminate against Medicare patients. Make Medicare means based. Require all Certificate of Need, taxpayer supported, or research grant holding facility to participate in Medicare. Bar doctors discriminating against Medicare patients from having admitting rights at any Certificate of Need, Research grant receiving, or Public hospital. Monetize our taxpayer supported internship hospitals (pretty much all of them) and charge doctors for the cost of their internship. If the doctor chooses to not serve Medicare/VA patients, then they shall be responsible for paying back the taxpayers for the cost of that education.
Since corporations would get a massive benefit due to the fact that healthcare would now be a means based entitlement, and they'd be no longer required to provide coverage, it makes sense to finance it partially from a 10 percent corporate surtax. I think most companies would gladly make that switch.
Private doctors and insurance companies would still exist. They'd just not be living off of government subsidies while doing so. I doubt that many would be able to make much of a living doing so though.
And yes, people would still be doctors, just like they are in every other country in the G20, all of whom have medical systems that have means based healthcare of one form of another.

This is the entitled generation's way to say F U to the entire health care establishment. I'm sorry but that's exactly how to screw up health care and our economy completely.

We have just gotten corporate taxes somewhat in line with the G20/OECD, where corporations don't pay for health care except to the extent they supplement in systems that allow it. Kicking those taxes back up will inevitably drive even more corporations offshore. They have no choice.

And universal systems are not need based. They can't be both universal and means based.

Do Bismarck, Medicaid becomes redundant, and Medicare can be phased out over time (or just rolled into Bismarck, sine the two operate similarly with base care plus supplementals). And fund it with a consumption tax, just like most of the G20 do.

(05-07-2018 05:14 PM)Owl 69/70/75 Wrote:  

(05-07-2018 03:23 PM)Tom in Lazybrook Wrote:  Just allow everyone to buy into Medicare. Double the number of medical school slots and make those slots only for doctors that promise to serve Medicare patients for the remainder of their American medical careers. Block Insurance companies from taking profits from reserves as a result of reductions in coverage, or number of covered persons. Tie US pharmaceutical prices to the G20 average price. Bar NIH or other Federal grant research money to facilities that discriminate against Medicare patients. Make Medicare means based. Require all Certificate of Need, taxpayer supported, or research grant holding facility to participate in Medicare. Bar doctors discriminating against Medicare patients from having admitting rights at any Certificate of Need, Research grant receiving, or Public hospital. Monetize our taxpayer supported internship hospitals (pretty much all of them) and charge doctors for the cost of their internship. If the doctor chooses to not serve Medicare/VA patients, then they shall be responsible for paying back the taxpayers for the cost of that education.
Since corporations would get a massive benefit due to the fact that healthcare would now be a means based entitlement, and they'd be no longer required to provide coverage, it makes sense to finance it partially from a 10 percent corporate surtax. I think most companies would gladly make that switch.
Private doctors and insurance companies would still exist. They'd just not be living off of government subsidies while doing so. I doubt that many would be able to make much of a living doing so though.
And yes, people would still be doctors, just like they are in every other country in the G20, all of whom have medical systems that have means based healthcare of one form of another.

This is the entitled generation's way to say F U to the entire health care establishment. I'm sorry but that's exactly how to screw up health care and our economy completely.

We have just gotten corporate taxes somewhat in line with the G20/OECD, where corporations don't pay for health care except to the extent they supplement in systems that allow it. Kicking those taxes back up will inevitably drive even more corporations offshore. They have no choice.

And universal systems are not need based. They can't be both universal and means based.

Do Bismarck, Medicaid becomes redundant, and Medicare can be phased out over time (or just rolled into Bismarck, sine the two operate similarly with base care plus supplementals). And fund it with a consumption tax, just like most of the G20 do.

If you make the payment for Medicare buyin means based, then it would be both universal and means based.

(05-07-2018 11:05 PM)Tom in Lazybrook Wrote:  

(05-07-2018 05:14 PM)Owl 69/70/75 Wrote:  

(05-07-2018 03:23 PM)Tom in Lazybrook Wrote:  Just allow everyone to buy into Medicare. Double the number of medical school slots and make those slots only for doctors that promise to serve Medicare patients for the remainder of their American medical careers. Block Insurance companies from taking profits from reserves as a result of reductions in coverage, or number of covered persons. Tie US pharmaceutical prices to the G20 average price. Bar NIH or other Federal grant research money to facilities that discriminate against Medicare patients. Make Medicare means based. Require all Certificate of Need, taxpayer supported, or research grant holding facility to participate in Medicare. Bar doctors discriminating against Medicare patients from having admitting rights at any Certificate of Need, Research grant receiving, or Public hospital. Monetize our taxpayer supported internship hospitals (pretty much all of them) and charge doctors for the cost of their internship. If the doctor chooses to not serve Medicare/VA patients, then they shall be responsible for paying back the taxpayers for the cost of that education.
Since corporations would get a massive benefit due to the fact that healthcare would now be a means based entitlement, and they'd be no longer required to provide coverage, it makes sense to finance it partially from a 10 percent corporate surtax. I think most companies would gladly make that switch.
Private doctors and insurance companies would still exist. They'd just not be living off of government subsidies while doing so. I doubt that many would be able to make much of a living doing so though.
And yes, people would still be doctors, just like they are in every other country in the G20, all of whom have medical systems that have means based healthcare of one form of another.

This is the entitled generation's way to say F U to the entire health care establishment. I'm sorry but that's exactly how to screw up health care and our economy completely.
We have just gotten corporate taxes somewhat in line with the G20/OECD, where corporations don't pay for health care except to the extent they supplement in systems that allow it. Kicking those taxes back up will inevitably drive even more corporations offshore. They have no choice.
And universal systems are not need based. They can't be both universal and means based.
Do Bismarck, Medicaid becomes redundant, and Medicare can be phased out over time (or just rolled into Bismarck, sine the two operate similarly with base care plus supplementals). And fund it with a consumption tax, just like most of the G20 do.

If you make the payment for Medicare buyin means based, then it would be both universal and means based.

No, because some people would elect not to buy in, as with Obamacare.

(05-07-2018 05:14 PM)Owl 69/70/75 Wrote:  

(05-07-2018 03:23 PM)Tom in Lazybrook Wrote:  Just allow everyone to buy into Medicare. Double the number of medical school slots and make those slots only for doctors that promise to serve Medicare patients for the remainder of their American medical careers. Block Insurance companies from taking profits from reserves as a result of reductions in coverage, or number of covered persons. Tie US pharmaceutical prices to the G20 average price. Bar NIH or other Federal grant research money to facilities that discriminate against Medicare patients. Make Medicare means based. Require all Certificate of Need, taxpayer supported, or research grant holding facility to participate in Medicare. Bar doctors discriminating against Medicare patients from having admitting rights at any Certificate of Need, Research grant receiving, or Public hospital. Monetize our taxpayer supported internship hospitals (pretty much all of them) and charge doctors for the cost of their internship. If the doctor chooses to not serve Medicare/VA patients, then they shall be responsible for paying back the taxpayers for the cost of that education.
Since corporations would get a massive benefit due to the fact that healthcare would now be a means based entitlement, and they'd be no longer required to provide coverage, it makes sense to finance it partially from a 10 percent corporate surtax. I think most companies would gladly make that switch.
Private doctors and insurance companies would still exist. They'd just not be living off of government subsidies while doing so. I doubt that many would be able to make much of a living doing so though.
And yes, people would still be doctors, just like they are in every other country in the G20, all of whom have medical systems that have means based healthcare of one form of another.

This is the entitled generation's way to say F U to the entire health care establishment. I'm sorry but that's exactly how to screw up health care and our economy completely.

We have just gotten corporate taxes somewhat in line with the G20/OECD, where corporations don't pay for health care except to the extent they supplement in systems that allow it. Kicking those taxes back up will inevitably drive even more corporations offshore. They have no choice.

And universal systems are not need based. They can't be both universal and means based.

Do Bismarck, Medicaid becomes redundant, and Medicare can be phased out over time (or just rolled into Bismarck, sine the two operate similarly with base care plus supplementals). And fund it with a consumption tax, just like most of the G20 do.

If we spent like most G20's we already spend roughly enough out of Medicare, Medicaid and VA to pay for it.

My doctor is in practice with three others. They have an APN working for them and four other nurses. They have a receptionist and four billing clerks. He told me he went to a conference and was talking to a doctor from Canada who was also in family practice. They got to talking the business of being doctors. The Canadian was in a five physician practice, they had five nurses, one receptionist and one billing clerk. My doctor finally asked him about money, and after converting for the exchange rate, the Canadian was making just over 90% of what my doctor makes in decent part because the Canadian had lower overhead. Not having to chase patients for copays and co-insurance helps.

We have a very anti-business system.
We have higher corporate tax rates and our effective rates are all over the place favoring large business over small business.
Even in nations where they rely on employers paying part of the health care premiums they are paying much less per employee. Their worker's comp premiums don't cover medical costs, their tort insurance doesn't cover medical either.

Get this straightened out and you can make a serious dent in the budget.

I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

I'd support a free market option for doctors and hospitals, so long as they're really 'free market' solutions. That means that if you're in the free market....no taxpayer subsidies

No NIH, CDC, or other government research grants for hospitals not in the public plan.
No Certificate of Need or HHS funding for hospitals that don't participate
Private doctors should pay the real cost of their internships if they leave the system
Private doctors should pay the real cost of the medical training in they leave the system
Private doctors should have no admitting rights at taxpayer funded hospitals

If the 'private sector' people want to set up a truly 'private' medical system, they're free to attempt to do it. But lets make it truly private. What we have now is that the costs are socialized for the companies/doctors (not the patients) but the profits are part of the free market system.

(05-08-2018 09:49 AM)Tom in Lazybrook Wrote:  

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

I'd support a free market option for doctors and hospitals, so long as they're really 'free market' solutions. That means that if you're in the free market....no taxpayer subsidies
No NIH, CDC, or other government research grants for hospitals not in the public plan.
No Certificate of Need or HHS funding for hospitals that don't participate
Private doctors should pay the real cost of their internships if they leave the system
Private doctors should pay the real cost of the medical training in they leave the system
Private doctors should have no admitting rights at taxpayer funded hospitals
If the 'private sector' people want to set up a truly 'private' medical system, they're free to attempt to do it. But lets make it truly private. What we have now is that the costs are socialized for the companies/doctors (not the patients) but the profits are part of the free market system.

So what you want to do is create a two tier market with two different groups with wildly differing cost structures? How is the result not inevitably Cadillac care for the rich and crap care for the rest?

Why not do like French Bismarck and you get free med school as long as you commit to work for a salary on the “free” side for a period of, say, 10 years, and after that you are judged to have repaid your debt to society and are free to enter private practice?

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

This is a free market solution to drug prices that would lower the cost to Americans.

https://www.realclearpolitics.com/articl...36997.html

We are doing trade negotiations with the Europeans. Right now, we subsidize the R&D for drugs for the entire world. The idea is to make them pay more of the free market price with the result being more drugs and a lower overall price, especially in the USA.

(05-08-2018 07:00 PM)Owl 69/70/75 Wrote:  

(05-08-2018 09:49 AM)Tom in Lazybrook Wrote:  

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

I'd support a free market option for doctors and hospitals, so long as they're really 'free market' solutions. That means that if you're in the free market....no taxpayer subsidies
No NIH, CDC, or other government research grants for hospitals not in the public plan.
No Certificate of Need or HHS funding for hospitals that don't participate
Private doctors should pay the real cost of their internships if they leave the system
Private doctors should pay the real cost of the medical training in they leave the system
Private doctors should have no admitting rights at taxpayer funded hospitals
If the 'private sector' people want to set up a truly 'private' medical system, they're free to attempt to do it. But lets make it truly private. What we have now is that the costs are socialized for the companies/doctors (not the patients) but the profits are part of the free market system.

So what you want to do is create a two tier market with two different groups with wildly differing cost structures? How is the result not inevitably Cadillac care for the rich and crap care for the rest?

Why not do like French Bismarck and you get free med school as long as you commit to work for a salary on the “free” side for a period of, say, 10 years, and after that you are judged to have repaid your debt to society and are free to enter private practice?

Any system needs to look at unnecessary costs. The cost of medical school limits supply, but doesn't cause that much of the cost inflation. More important is using PAs when doctors aren't really needed. We need to look at tort costs (and related CYA testing). We need to look at insurance companies as an inefficient (and often corrupt) middleman. And, of course, drugs.

(05-09-2018 09:14 AM)bullet Wrote:  

(05-08-2018 07:00 PM)Owl 69/70/75 Wrote:  

(05-08-2018 09:49 AM)Tom in Lazybrook Wrote:  

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

I'd support a free market option for doctors and hospitals, so long as they're really 'free market' solutions. That means that if you're in the free market....no taxpayer subsidies
No NIH, CDC, or other government research grants for hospitals not in the public plan.
No Certificate of Need or HHS funding for hospitals that don't participate
Private doctors should pay the real cost of their internships if they leave the system
Private doctors should pay the real cost of the medical training in they leave the system
Private doctors should have no admitting rights at taxpayer funded hospitals
If the 'private sector' people want to set up a truly 'private' medical system, they're free to attempt to do it. But lets make it truly private. What we have now is that the costs are socialized for the companies/doctors (not the patients) but the profits are part of the free market system.

So what you want to do is create a two tier market with two different groups with wildly differing cost structures? How is the result not inevitably Cadillac care for the rich and crap care for the rest?

Why not do like French Bismarck and you get free med school as long as you commit to work for a salary on the “free” side for a period of, say, 10 years, and after that you are judged to have repaid your debt to society and are free to enter private practice?

Any system needs to look at unnecessary costs. The cost of medical school limits supply, but doesn't cause that much of the cost inflation. More important is using PAs when doctors aren't really needed. We need to look at tort costs (and related CYA testing). We need to look at insurance companies as an inefficient (and often corrupt) middleman. And, of course, drugs.

Tort is not an issue. When there's a limit for damages capped at less than a week's salary for some hosptial corp CEO's that's not really much of a cost.

The lack of Medical school SLOTS is what drives up price.

The insurance industry appears to be nothing more than a rent taker, that provides zero value to the system.

(05-09-2018 09:14 AM)bullet Wrote:  

(05-08-2018 07:00 PM)Owl 69/70/75 Wrote:  

(05-08-2018 09:49 AM)Tom in Lazybrook Wrote:  

(05-08-2018 09:38 AM)Claw Wrote:  I won't support any of these centralist solutions unless there is an amendment protecting the right to free-market solutions first.

I'd support a free market option for doctors and hospitals, so long as they're really 'free market' solutions. That means that if you're in the free market....no taxpayer subsidies
No NIH, CDC, or other government research grants for hospitals not in the public plan.
No Certificate of Need or HHS funding for hospitals that don't participate
Private doctors should pay the real cost of their internships if they leave the system
Private doctors should pay the real cost of the medical training in they leave the system
Private doctors should have no admitting rights at taxpayer funded hospitals
If the 'private sector' people want to set up a truly 'private' medical system, they're free to attempt to do it. But lets make it truly private. What we have now is that the costs are socialized for the companies/doctors (not the patients) but the profits are part of the free market system.

So what you want to do is create a two tier market with two different groups with wildly differing cost structures? How is the result not inevitably Cadillac care for the rich and crap care for the rest?
Why not do like French Bismarck and you get free med school as long as you commit to work for a salary on the “free” side for a period of, say, 10 years, and after that you are judged to have repaid your debt to society and are free to enter private practice?

Any system needs to look at unnecessary costs. The cost of medical school limits supply, but doesn't cause that much of the cost inflation. More important is using PAs when doctors aren't really needed. We need to look at tort costs (and related CYA testing). We need to look at insurance companies as an inefficient (and often corrupt) middleman. And, of course, drugs.

Limiting supply inherently causes prices to rise. Agree that using PAs/NPs is a way to reduce costs. If we did Bismarck, I think the insurers would start experimenting with ways to reduce costs on basic services--doc in a box, NPs/PAs, and so forth--in order to make their basic plans more competitive.

(05-09-2018 10:32 AM)Tom in Lazybrook Wrote:  Tort is not an issue. When there's a limit for damages capped at less than a week's salary for some hosptial corp CEO's that's not really much of a cost.
The lack of Medical school SLOTS is what drives up price.
The insurance industry appears to be nothing more than a rent taker, that provides zero value to the system.

Tom, you're the attempted rent taker. You want everybody else to take care of your unique needs, and do it for free. And no system does that.

You thought you were going to be an Obamacare winner. Turns out that your'e a loser. You didn't expect that, so you are pissed. Too bad.